Carol Tekavec, RDH
Coding for periodontal procedures always is problematic. Sometimes, it seems like there are more potential treatment options than there are codes to describe them. In addition, insurance-carrier benefit restrictions increasingly are making the patient responsible for paying for periodontal care. For the general practice, coding and reimbursement for periodontal scaling and root-planing (Code 04341) and periodontal-maintenance procedures (Code 04910) seem to produce the most consistent benefit problems.
Scaling and root-planing
This common procedure may result in benefit problems if data collection for the patient is not reported in a certain way. Most insurance carriers want to have "Case Type" classifications (i.e., Case Type III-V), as well as a detailed charting of probing depths, recession, bleeding, mobility, and furcations. An increasing number of carriers are requesting probing depths listed as "loss of attachment" or "depth of pocket from the CEJ" in order for benefits to apply. Both measurements actually indicate pocket depth plus recession, and typically must be 5 mm or more for consideration. A few carriers are looking for "reduction of the alveolar crest levels beyond 1.5 - 2.0 mm proximity to the CEJ." This is yet another way to describe loss of attachment.
A chart form that provides data collection for these measurements and several subsequent maintenance appointments (Comprehensive Periodontal Examination C-103R) available from Stepping Stones to Success is the easiest and usually the quickest way to document the patient`s condition. A photocopy of the charting form with all pertinent information completed, along with radiographs (periapicals or vertical bitewings) can be attached to the claim form.
Many carriers also have minimum tooth eligibility for full-quadrant benefits to apply. Most require at least four involved teeth per quadrant. If fewer than four teeth need root-planing, the quadrant can be reported as a fraction - i.e., 3/4 of a quad for three teeth, 2/4 of a quad for two teeth. Payment for Code 04341, Periodontal Scaling and Root-Planing, usually is based on four separate quadrants once every two years. Some carriers stretch that time period to four quadrants once every 28 months.
"Quadrants per visit" also may limit insurance payment. Most carriers allow a lesser benefit for a full-mouth, four-quadrant (Code 04341) performed on the same day than they do for a two-quadrant/per visit procedure. Patients requiring full-mouth, four-quadrant treatment for whatever reason may receive a complete benefit when the office provides a written explanation. Many carriers allow benefits without predetermination for up to $300 for eligible periodontal therapy. This can be helpful for patients presenting with immediate needs and limited funds.
A benefit for a periodontal-maintenance procedure (Code 04910) usually applies three months after root-planing has been completed. Code 04910 only is appropriate following periodontal surgery or after Code 04341, Periodontal Scaling and Root-Planing. It is not appropriate for the "difficult" prophy or following Code 04355, Full-Mouth Debridement. Although often recommended at least four times per year, normally this code is a benefit only twice per year.
Since 1995, the ADA CDT-2 has indicated that Code 04910 does not include a periodic oral evaluation (Code 00120); however, few carriers have paid a separate benefit for the exam. In the year 2000, the new ADA CDT-3 is expected to define Code 04910, Periodontal-Maintenance Procedure, as including an examination (as did the CDT-1 from 1990-1995). It is important to note that no separate code or benefit exists for periodontal probing, which is an important factor in completion of Code 04910. The ADA considers full-mouth periodontal probing to be part of an adequate exam. Insurance carriers consider periodontal probing to be part of a larger procedure and, therefore, not separately payable.
Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.